Guarantor# Financial Assistance Process & Application Terrebonne General Medical Center (TGMC) is committed to providing financial assistance for patients with a demonstrated financial need or hardship, who have received medically necessary healthcare services provided by TGMC. Medically necessary services are services that are reasonable or necessary for the diagnosis or treatment of an illness or injury. Medical necessity will be determined by the examining physician. This application does not serve as a guarantee of financial assistance or reduction in outstanding liability. Forms to include: TGMC Financial Assistance Application TGMC Patient Attestation Documentation to include: 1. Copy of most recently filed income tax return OR a copy of three (3) most recent pay stubs for yourself and co-applicant. a. If unemployed, please provide a letter from last employer OR copy of unemployment aware letter OR letter certifying denial of unemployment benefits from applicable state department of labor 2. Last 2 months bank statements for yourself and co-applicant. **Lines 1 and 2 must be included for your application to be processed; if you do not have these items, please provide a written statement advising of such** If Applicable: 1. Copy of Social Security Administration monthly award letter 2. Copy of Disability monthly award letter 3. Copy of healthcare insurance card/information 4. Any and all other income: a. Spousal/Child Support b. Rental Property c. Investment Income 5. Medicaid denial determination 6. Proof of dependents (birth certificates or most recently filed income tax return) **If any of the above applies, we will not be able to process your application without such documentation if applicable**
Please Mail Completed Info to: Terrebonne General Medical Center Department: Patient Responsibility Attn: Jennifer Dufrene 8166 Main Street Houma, LA 70360 Income Information: Please complete the income information below. Please state if the income listed is per month or per year. If married, please include spouse income information under the Co-Applicant fields Income Sources Applicant Per Month/Year Co-Applicant Per Month/Year Employment $ $ Social Security $ $ Disability $ $ Unemployment $ $ Rental Property $ $ Investment Income $ $ Spousal Support $ $ Child Support $ $ Total Combined Income $ Applicant(s) Information Applicant/Guarantor Information Relationship to Patient: Marital Status (*): [ ]Self [ ]Spouse [ ]Parent [ ]Single [ ]Married [ ]Divorced [ ]Separated *If Married, please include spouse information and income [ ]Yes [ ]No Last Name First Name Middle Initial U.S. Citizen Social Security Number Date of Birth Number of Dependents Age of Dependents Current Telephone Number Street Address City, Parish, State ZIP Current Employer City, Parish, State Position If you are not working, how long have you been unemployed?
Co-applicant Information Relationship to Patient: [ ]Self [ ]Spouse [ ]Parent *If Married, please include spouse information and income [ ]Yes [ ]No Last Name First Name Middle Initial U.S. Citizen Social Security Number Date of Birth Number of Dependents Age of Dependents Current Telephone Number Street Address City, Parish, State ZIP Current Employer City, Parish, State Position If you are not working, how long have you been unemployed?
Attestation I have complied with the Terrebonne General Medical Center Financial Assistance Program ( FAP ) screening process to determine if I may be eligible for alternate resources (COBRA, Social Security, Medicaid, and Victim of Crime). I understand that until I have complied with the FAP eligibility process, or applicable application process, I will not be eligible for financial assistance. I understand that balances due to non-medically necessary services, such as purely elective or cosmetic services are not eligible for financial assistance, and I have not included any of those balances in this request. If I have included balances due to purely elective or cosmetic services, they will not be adjusted. If they are adjusted in error, they will be reinstated. If applicable, I have provided my most recent/current insurance card with appropriate information to submit past, present and future claims. I have provided all requested documentation from page 1 of this application. I attest that all information provided, as well as all supporting documents are accurate and truthful to the best of my knowledge and ability. Printed Name Date of Application Signature Phone/Contact Address (Street Address, City, State, Zip) Attachment(s):
TGMC Financial Assistance Application and all applicable required documents No Income Verification/Statement of Support _ (Applicant) is applying for financial assistance with the Terrebonne General Medical Center. The applicant has stated they do not receive any monthly/yearly income. The applicant has listed you as their sole means of support. To the best knowledge, the applicant has no income and I certify this to be true. I am either providing the applicant with food and shelter and/or providing the applicant with financial support as specified below: (Relationship to the applicant-for example: Shelter, Mother, Father, Other) I am providing: Food and Shelter $ Approximate monthly total Financial Support $ Approximate monthly total Other $ Approximate monthly total Printed Name (of supporter) Date Signature (of supporter) Phone/Contact Address (Street Address, City, State, Zip) If you have any questions or concerns, you may contact the Financial Counselor in the Patient Responsibility Department by phone at (985) 873-3799. Terrebonne General Medical Center Department: Patient Responsibility Attn: Jennifer Dufrene
8166 Main Street Houma, LA 70360